Service Area Strategic Plan
4/18/2014   7:34 am
Department of Behavioral Health and Developmental Services (720)
Biennium:
Service Area 1 of 1
Inpatient Pharmacy Services (720 421 02)
Description

Inpatient Pharmacy Services include medication selection and procurement, medication storage, medication ordering and prescribing, medication preparation and dispensing, medication administration, and medication monitoring. Medication orders are prepared, packaged, compounded (if needed), labeled and then sent directly to the individual's unit for administration by nursing staff. State facility pharmacies participate in the Minnesota multi-state consortium for the bulk purchase of drugs from pharmaceutical companies, allowing the Department to leverage best value and drug purchases. The state facility pharmacies maintain a formulary and promote the use of generics and dose manipulation (for example, two 50 mg tablets in the place of one 100 mg tablet) to reduce prescription product cost. They educate physicians on cost effective, evidence-based practices and interventions and provide drug information to facility medical and nursing staff and to patients and their families, as required or requested.
Background Information
Mission Alignment and Authority
  • Describe how this service supports the agency mission
    State hospitals and training centers continue to be critical components in the Commonwealth's behavioral health and developmental services system. These facilities share a collective responsibility to assure the provision of appropriate services and supports, including medications to alleviate the symptoms and distress associated with the individual's illness and medical condition.
  • Describe the Statutory Authority of this Service
    Chapter 3 of Title 37.2 of the Code of Virginia establishes the Department of Behavioral Health and Developmental Services.
    • § 37.2-304 outlines the duties of the Commissioner, including supervising and managing the Department and its state facilities, including inpatient pharmacy services.

    Chapter 7 of Title 37.2 of the Code of Virginia authorizes the Department to perform certain functions related to the operation of state facilities, including inpatient pharmacy services.
    • § 37.2-.703 authorizes the Commissioner to prescribe a system of records, accounts, and reports of how money is received and disbursed and of consumers admitted to or residing in each state facility;
    • § 37.2-704 authorizes the Commissioner to receive and expend social security and other federal payments for consumers in state facilities; and
    • §§ 37.2-717 through 37.2-721 direct the Department to investigate and determine which consumers or parents, guardians, conservators, trustees, or other persons legally responsible for consumers are financially able to pay for care; to assess or contract with such individuals to recover expenses; and to pursue payment of such expenses.
Customers
Agency Customer Group Customer Customers served annually Potential annual customers
Individuals receiving state facility inpatient pharmacy services Individuals served by state facility pharmacies 6,866 6,866

Anticipated Changes To Agency Customer Base
o Virginia’s population is increasing, becoming more culturally diverse, and growing older. The customer base for inpatient pharmacy services will change to reflect these demographic trends.

o State facilities will serve proportionately greater numbers of individuals with significant or complex service needs who will require specialized treatment services and ongoing preventive care.

o State facilities will serve proportionately greater numbers of individuals with co-occurring disorders (mental illnesses and substance use disorders, intellectual disability and/or other developmental disabilities), increased individual acuity, and complicated acute and chronic medical needs.

o State facilities will serve proportionately greater numbers of individuals who have some level of involvement with the criminal justice system.

o A growing number of Virginians have either limited or no behavioral health insurance benefits. These individuals will place increasing pressure the public behavioral health and developmental services system.
Partners
Partner Description
Department of Medical Assistance Services: The Department of Medical Assistance Services funds many services and supports, including medications, for Medicaid enrolled facility patients and residents.
Individuals receiving services, family members, and advocacy organizations: Individuals receiving services, family members, and advocates provide important feedback to the Department on pharmacy needs and services.
Local acute care hospitals: State facilities share formulary information with local hospitals to ensure continuity of care for individuals admitted to their care who require hospitalization for short periods of time in local hospitals.
Products and Services
  • Factors Impacting the Products and/or Services:
    o Individuals served state hospital civil beds should continue to decline as more community-based crisis intervention services become available. Demand for beds to serve individuals with forensic involvement is likely to continue to increase over time as Virginia's population grows and new commitment criteria are fully implemented.

    o Children and adolescents served in state hospitals will continue to have extreme needs or some interaction with criminal justice system. The Department has convened a planning group comprised of families, community providers, advocates, and others, to examine the current and future role of the Commonwealth and private providers in providing acute psychiatric services for children and adolescents and to develop strategies for promoting high-quality community-based care while maintaining a safety net of services for children and adolescents who need acute psychiatric services.

    o Individuals served in training centers are increasingly presenting with pervasive co-occurring physical disabilities or medical conditions such as seizures, scoliosis, or gastrointestinal problems and co-occurring mental illness and challenging behaviors.

    o The current state facility pharmacy computer system was purchased in the 1980s and is outdated and inadequate. The system cannot communicate with other data systems such as the Department’s billing system and patient demographics database.

    o State facility pharmacies are accepting all Medicare Part D third party payers and billing on behalf of all eligible parties, increasing demand on the pharmacies.

    o Increasing numbers of individuals receiving state facility services are medically uninsured or underinsured, which will result in unrecoverable medication costs.

    o The cost to treat Americans under care for depression and other mental illnesses rose by nearly two-thirds to $58 billion from $35 billion in a 10-year period, according to the Agency for Healthcare Research and Quality. A new analysis by AHRQ shows the number of Americans treated for mental disorders, such as depression and bipolar disease, nearly doubled to 36 million from 19 million from 1996 to 2006. Also, researchers found that heart conditions, cancer, trauma-related disorders, mental disorders and asthma ranked highest in terms of direct medical spending in 1996 and 2006, while the relative increase in costs to treat mental disorders topped the list during that period. Of those five conditions, cancer accounted for the highest per-patient cost, as it rose to $5,176 per person versus the earlier cost of $5,067 per patient. Meanwhile, out-of-pocket payments were highest for the treatment of mental disorders in both 1996 and 2006 (23.1 percent and 25.0 percent, respectively).

    o There is a pharmacist shortage in Virginia and nationally. The Department's pharmacist salaries are the lowest in the state, making recruitment and retention of pharmacists extremely difficult.
  • Anticipated Changes to the Products and/or Services
    As part of its electronic health record (EHR) initiative, the Department is in the process of replacing its outdated stand-alone pharmacy system with one that can assist in adequately managing the accurate and safe dispensing of medications. The Department has contracted with General Electric's Pharmacy Services System ("Centricity") for implementation this fiscal year. This system would manage pharmacy functions, including prescription entry, medication dispensing, inventory control, reimbursement, and quality assurance. The replacement system would be integrated with the Department’s AVATAR system, which is used for individual admissions, discharges, and reimbursement functions. .
  • Listing of Products and/or Services
    • Medication Preparation and Dispensing -- State facility pharmacies dispense drugs to facility patients and residents. Medication orders are prepared, packaged, compounded (if needed), labeled and then sent directly to the unit where the patient is located for administration by nursing staff.
    • Medication Selection and Procurement -- State facility pharmacies participate in the Minnesota multi-state consortium for the bulk purchase of drugs from pharmaceutical companies. This enables the Department to purchase drugs at a reduced cost.
    • Service Oversight and Cost Containment -- State facility pharmacies maintain a formulary and promote the use of generics and dose manipulation (for example, two 50 mg tablets in the place of one 100 mg tablet) to reduce prescription product cost and educate physicians on cost effective, evidence-based practices and interventions.
    • Medication Management and Education -- State facility pharmacies provide drug information to health professionals within the facility (medical staff, nursing staff, etc.), and to patients and their families, as required or requested.
Finance
  • Financial Overview
    This service area is funded with 100 percent non-general funds. Non-general funds are derived from the collection of fees from Medicaid, Medicare, private insurance, private payments, and Federal entitlement programs related to patient care.

    Note: The information on the following table is presented at the service area level. However, funding by fund source is appropriated at a higher program level. This results in the allocation of the non-general fund amounts to the various service areas within the program level in accordance with reasonable allocation methodology. Such methodology has been applied and is represented in these amounts.
  • Financial Breakdown
    FY 2011    FY 2012
      General Fund     Nongeneral Fund        General Fund     Nongeneral Fund  
    Base Budget $40,732 $18,673,519    $40,732 $18,673,519
    Change To Base $0 $0    $0 $0
               
    Service Area Total   $40,732  $18,673,519     $40,732  $18,673,519 
Service Area Objectives
 
  • Provide appropriate pharmacy services to individuals receiving services and supports in state hospitals and training centers.
    Objective Description
    Medications dispensed by state facility pharmacies are an important component in treating many psychiatric and medical conditions experienced by individuals receiving state hospital and training center services. Antipsychotic polypharmacy, the taking of two or more antipsychotic drugs at the same time, is a concern for state facility prescribers and individuals receiving services. Data suggests that the results of prolonged antipsychotic polypharmacy may lead to increased adverse effects. Consensus guidelines recommend monotherapy as the standard of care, with antipsychotic polypharmacy as the last resort in order to reduce medication complexity and reduce the risk of adverse events. This is a Joint Commission Core Measure reported by the Department for each individual discharged from the state hospitals.
    Alignment to Agency Goals
    • Agency Goal: Expand and sustain services capacity necessary to provide services when and where they are needed, in appropriate amounts, and for appropriate durations.
    • Agency Goal: Assure that services system infrastructure and technology efficiently and appropriately meet the needs of individuals receiving publicly funded behavioral health and developmental services and supports.
    Objective Strategies
    • Monitor physician prescribing practices to identify potential prescribing issues and take appropriate actions.
    • Implement an automated pharmacy information system in the state facility pharmacies as part of the Department’s Electronic Health Records initiative.
    • Monitor inventory to reduce excess inventories and price discrepancies while ensuring the availability of normal stock levels for medications.
    • Continually evaluate and ensure the capacity of state facility pharmacies to bill a variety of third party insurance plans.
    • Ensure that current state facility pharmacies’ procedures and capabilities comply with state requirements and federal programs.
    • Implement 30-day and 90-day medication reviews as required by federal and state regulatory agencies, (Medicare, Medicaid, Virginia Board of Pharmacy).Medicaid, Virginia Board of Pharmacy).
    • Implement the "Centricity" automated pharmacy information system in FY 2010 as part of the Department’s Electronic Health Records initiative.
    Link to State Strategy
    • nothing linked
    Objective Measures
    • Percentage of consumers who have been identified as receiving two or more antipsychotic medications upon discharge from a state facility.
      Measure Class:
      Other
      Measure Type:
      Outcome
      Measure Frequency:
      Annual
      Preferred Trend:
      Down

      Frequency Comment: The percentage for FY 09 will be calculated to determine the baseline and the FY 12 goal will reflect a 6% reduction from that baseline.

      Measure Baseline Value:
      TBD
      Date:
      6/30/2009

      Measure Baseline Description: Percent of consumers prescribed 2 or more antipsychotic medications at discharge

      Measure Target Value:
      TBD
      Date:
      6/30/2012

      Measure Target Description: Percent of consumers prescribed 2 or more antipsychotic medications at discharge

      Data Source and Calculation: Source: MEDIS and state facility pharmacy systems Calculation: Number of the individuals discharging with prescriptions for more two or more antipsychotic drugs divided by the total number of discharges for the same time period.


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